Provider Demographics
NPI:1295714343
Name:CORRY, RAYMOND WALTER (OD)
Entity type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:WALTER
Last Name:CORRY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 W LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52803-2806
Mailing Address - Country:US
Mailing Address - Phone:563-324-2020
Mailing Address - Fax:563-323-0949
Practice Address - Street 1:310 W LOCUST ST
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52803-2806
Practice Address - Country:US
Practice Address - Phone:563-324-2020
Practice Address - Fax:563-323-0949
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1705152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1004341Medicaid
IA37841OtherBLUE CROSS BLUE SHIELD
IAI14298Medicare ID - Type Unspecified
IA37841OtherBLUE CROSS BLUE SHIELD